OUR LADY OF FATIMA UNIVERSITY College of Nursing Regalado, Fairview Quezon City

HOSPITAL OF AFFILIATION: Ospital ng Lungsod ng San Jose del Monte Bulacan AREA/WARD: Delivey Room DATE OF CLINICAL EXPOSURE: July 28 and 29,2011 DAY AND TIME OF CLINICAL EXPOSURE: Wedneday and Thursday/ 7:00am-7:00pm PATIENT PROFILE NAME: April Diaz Morales ADDRESS: B5 L21 area F Purok 3 Kamagong St.City of SJDM DATE ADMITTED: July 28,2011 DR. INCHARGE: Dra.Perez DIAGNOSIS: G1 Pu 30 weeks AOG CIL in Preterm Labor NURSING HISTORY PRESENT MEDICAL HISTORY: 1 day PTA (+) Fever (+) loss of appetite (+) hpogastric pain PAST MEDICAL HISTORY:N/A PATHOPHYSIOLOGY Preterm labor (PL) is the main cause for hospital admission during pregnancy. 50% of all pregnant women are diagnosed with PL. 7% of all neonates are born prematurely and one third of all preterm births follow PL with intact membranes. Previous history of preterm delivery, young maternal age, low socio-economical status are established risk factors of PL with intact membranes. Intrauterine infection, abruptio placenta praevia and uterine and cervical anomalies are often associated with PL with intact membranes. Cytokines, cortico-releasing hormone and the fetal hypothalamic-pituitary-adrenal axis could trigger the prostaglandin cascade leading to PL. However data are lacking to conclude. Intrauterine infection can also lead to neonatal infection in the preterm babies. This is also an important risk factor of cerebral lesions and cerebral palsy. Outside perinatal infection, PL does not seem to increase neonatal death and neonatal morbidity compared with other causes of preterm delivery.

DIAGNOSTIC PROCEDURE Ultrasound- done June 21,2011 Hematology- done July 24,2011 Urinalysis- done July 28, 2011

DRUG STUDY

ASSESMENT
NAME

DIAGNOSIS
INDICATION

PLANNING
CLASSIFICATION SIDE EFFECTS

INTERVENTION

EVALUATION
NURSING

CONTRAINDICATIONS

Generic/Brand/Dosage Subjective:humihilab

After 8 hours of nursing After RESPONSIBILITIES 8 hours of Activity in >assess the status intervention the patient nursing ang titan ko parang tolerance related will use to identified of the client and intervention the was able to managanganak na techniques to enhance patientBefore giving Cefuroxime to muscle fetus Preoperative or Cephalosporin CV: phlebitis, Contraindicated in activity in tolerance use identified patient if Ceftin dug. ask akoas verbalized by prevention thrombophleb patients cellular >encourage bed techniques to 750mg 1 tab BID itis she activity hypersensitive to enhance is allegic to the patient responsibility rest in side lying drug or other in tolerance or penicillin Objective: GI: diarrhea, cephalosporin. position anorexia, cephalosporin. >irritability vomiting >monitorcautiously in Use the vital Obtain specimen >facial grimace patients signs of the client Hematologic: hypersensitive to for culture and >restlessness hemolytic >instruct the client penicillin because sensitivity tests >v/s taken as follows: anemia, of possibility of to report of feeling thrombocytop cross-sensitivity before giving first Bp:110/70 of with other enia, transient difficulty of beta dose. absorption Pr:81 neutropenia, lactam antibiotics breathing and chest eosinophilia of oral drug is rr:20 pain induce temp:36.5 > Dexamethasone BRAND NAME: Cortastat, Dalalone, Decadrol, Decaject, Deronil, Dexacorten, Dexameth, Dexasone, Dexone, Hexadrol, Primethasone, Solurex 8mg every 8hours Adrenal insufficiency concomitantly mineralocortico id; inflammatory condition,allergi c states,cerebral edema and hematologic disoreders Hormones and synthetic substitutes adrenal corticosteroid,gl ucocorticoid Convulsion,he adache,bronch ial asthma,increa sed ICP, CHF,hyperten sion,edema,hy perglycemia,n ausea,heart burn,loss of muscle mass >avoid alcohol Acute infections,active or and caffeine resting >monitor BP tuberculosis,admini stration of live virus during vaccines stabilization period >assess patient >to take inflammatory on schedule and dont stop abruptly